clinical pharmacy final

8/12/2019 Clinical Pharmacy Final

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1 CLINICAL PHARMACY

AL SHIFA COLLEGE OF PHARMACY

DRUG INFORMATION QUERY

INTRODUCTION

The provision of drug information is the most fundamental responsibility of clinical

pharmacist. The information may be specific to an individual patient as an integral part of

pharmaceutical care, or relative to a group of patients, such as in the context of a disease

management programme. The term medicine is used to highlight the services related to

medicinal drugs rather than drug of abuse.

The term drug information was developed in early 1960s. The first drug information

centre was established at the University of Kentucky in 1962. However in India drug

information services and centres are still in their infancy and we have only a few services that

qualify as drug information centre.

Pharmacists have unique range of knowledge and skills which are required for drug

information practice. These include knowledge of pharmaceutics, pharmacology,

pharmacokinetics and pharmacotherapy. All of these are required to optimise the use of drugs

in treatment and prevention of disease.

DEFINITION

Drug information refers to the provision of unbiased, well referenced, and critically

evaluated up to date information on any aspect of drug use.

The drug information service (DIS) refers to activities that are part of the overall pharmacy

service or pharmaceutical care process.

Drug information centre (DIC) refers to the specialized facility that provides drug

information to those who need it.

A drug information specialist refers to a new breed of pharmacist who is expert in drug

information monitoring.

OBJECTIVES

To uplift the profession of pharmacy.

To improve patient compliance and therapeutic outcome.

To advise and educate patients for the proper use of drugs.

To advise and educate patients regarding drug addiction, alcoholism, smoking

hazards and other socio-medical problems.

Advise on self-medication for minor complaints.


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2 CLINICAL PHARMACY


Advise on public health issues.

Other activities like publishing newsletters or bulletins, conducting seminars, group

discussions, campaigns etc.

PROVIDERS OF DRUG INFORMATION

Knowledgeable about data storage and retrieval methods

Able to objectively evaluate scientific literature

Able to apply information to the specific patient situation

An effective communicator with patients, health care professionals, administrators

and the media.

MODIFIED METHOD TO ANSWER A DRUG INFORMATION ENQUIRY

There are many types of drug information requests. The most common relate to

therapeutics, adverse drug reactions, dosage and administration, drug interaction and use of

drugs in pregnancy and lactation. Other question may concern aspects of drug

pharmacokinetics, pharmaceutical stability, compatibility, poisoning, toxicity and drug

availability.

There are seven steps to answering an enquiry

STEP 1: Secure demographics of requester

The requesters name, position, training and anticipated knowledge are important to

determine the approach and final response to the question.

For example, an elderly patient and a cardiovascular specialist may each enquire about

the availability of an investigational medication; however each brings a different frame of

reference to the request.

STEP 2: Obtain background information

The ability to obtain background information is essential for systematic approach. Thishas been the most difficult step. Sufficient background information must be obtained in a

limited time period. The background questions should be specific for the nature of the

request. Background information includes the patients age, weight and sex. In addition, the

patients diagnosis, other medication such as co-morbidities and hepatic and renal function

are often important to assess. It is also advisable to find out if the requester has checked any

resources previously so as to avoid duplication of work. Finally the urgency of the request

should be ascertained.


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STEP 3: Determine and categories the ultimate question.

The ultimate question may differ significantly from the original question if the requester

posed a general question, and the pharmacist has used his expertise to obtain background

information. Adequate background information is needed to determine the ultimate question.

For example: if a doctor is concerned about the safety of prescribing Metronidazole to a

patient taking Simvastatin, the question can be categorized as a drug interaction query.

STEP 4: Develop search and conduct search

The information resources are selected based on the probability of containing the desired

data. For example given in step 3, standard references on drug interactions are first-line

resources as both simvastatin and metronidazole have been in clinical use for many years. If

one of the drugs was a recently introduced drug, a Medline search would be more

appropriate. The resources may be used based on ease of access or the pharmacistsfamiliarity with particular resources. The resources used in answering the question should be

documented and this will help in understanding the usefulness of various resources at times

of budget allocation.

STEP 5: Perform evaluation, analysis and synthesis

The information retrieved must be critically reviewed. Application of the techniques and

skill for literature evaluation and knowledge of statistical analysis may be used. For the

response to be relevant and useful to the requester, the information must be analysed and

synthesized with consideration of the background information obtained previously. Analysisinvolves the critical assessment of the nature and merit of factors which may be relevant to

the question. Synthesis involves the careful integration of critical information about the

patient, disease and medication along with pertinent background information to arrive at a

judgment or conclusion. Analysis and synthesis together assist in forming opinions, arriving

at judgment, and ultimately drawing conclusions.

STEP 6: Formulate and provide response

This involves a series of steps that must be performed completely, objectively and in a

logical sequence. Patient factors, disease factors, medication history and other relevant

background information and special circumferences should be considered. Once this data is

collected and carefully assembled it must be critically analysed and evaluated before

providing the final response. The way in which answers are communicated plays a major role

in determining how drug information is accepted by physician. The response to a question

must include restarting the request and clearly identifying the problems, issues and

circumstances that are relevant to the question. Specify recommendation must be

scientifically sound and clearly justified. In the hospital setting the majority of questions will

be answered verbally and responses should be brief, concise and accurate and provided in a

timely manner.


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STEP 7: Conduct follow-up and documentation

Follow- up is the process of verifying the appropriateness, correctness, and completeness

of a response after it has been given. When recommendations are made, follow-up should

always be done in a timely manner. This allows pharmacist to know if the recommendations

were accepted and implemented. Patient- specific requests generally provide opportunities for

follow-up. In a hospital setting this may involve visiting the ward and offering additional

advice and information. This type of follow-up provides opportunities for pharmacists to

become involved in direct patient care, independently of ward round participation or routine

patient counselling. Documentation of the DI query is essential for purposes of quality

assurance, budget allocation, and promotions of the DI service and to minimize liability. The

documentation may be as a simple form or an extensive review and summary of all processes

completed.

DRUG INFORMATION RESOURCES

Drug information is stored in a variety of media including textbooks, journals,

newsletters, microfiche, optical disks and computer systems. The information regarding the

drugs can be broadly classified into three categories

1. Primary resourcesPrimary literature consists of research studies or clinical experience which has not been

previously published. This includes clinical trials, short reports, case reports and letters to theeditor which describe clinical events such as adverse drug reactions or unexpected clinical

outcomes. Examples of journals which publish primary literature include:

Annals of Internal Medicine,

Lancet,

The New England Journal of Medicine,

Journal of American medical Association.

Advantage

Provide the most current information

Share opinion with other health professionals

Keeps abreast of professional news

Keeps up with the new developments in pathophysiology, diagnostic agents

and therapeutic regimen

Disadvantage

No guarantee of accuracy

Inadequacy of articles are common


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2. Secondary resourcesSecondary resources provide an overview of previously published work, and include

indexing and abstracting services of the primary literature. Examples of secondary resources

include the abstracting services like;

DRUGDEX

International Pharmaceutical Abstracts

The indexing services BIOSIS previews

ClinAlert

Embase

Iowa Drug Information System (IDIS) and Medicine. An indexing system

provides only bibliographic information that is indexed by topic and provides

the original abstract or full text with no interpretation. On the other hand, an

abstracting service provides content by interpreting the original reports andcreating summaries based on the abstracting services editorial guidelines.

PubMed from the National Library of Medicine. It is an examples of

Online resources

Advantage

Valuable tools for quick and selective screening of the primary literature for

specific information, data, citation and articles

Provide sufficient information to serve as references for answering drug

information requests

Disadvantage

Reviews a finite number of journals

Usually describe only articles and clinical studies

Abstracts are generally interpretations

3. Tertiary resourcesThese consist of general literature including textbooks and full-text computer database.

Examples of tertiary resources include

United States Pharmacopoeia Drugs,

Remingtons Pharmaceutical Sciences

Merck Index,

Red Book,

Martindale:

Tertiary resources are the most commonly used sources of information because they are

easy to use, convenient, concise, and compact.


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Advantage

Provide easy and convenient access to a broad spectrum of related topics

Background information on drugs and diseases available

Disadvantage

Gap between recent developments and actual publication of books

Omission of pertinent data

Misinterpretation of literature possible

4. InternetThe Internet expands the ability to search therapies that have been recently published or

discussed in the media. An Internet search maybe required for the following: company

specific information, issues currently in the news, alternative medicine, or U.S. government

information. The most popular Web browsers are Mozilla Firefox and Microsoft Internet

Explorer. A variety of search engines, software tools for searching the Internet, have been

developed. General search engines (AltaVista, Google, Yahoo, Ask, Dogpile) attempt to

index as much of the Internet as possible.

Disadvantage

Information obtained may not be peer reviewed or edited before release.

Information may be only as reliable as the person who posted it and the users

who read and comment on its content.

A web site should be evaluated by its source (author) of information. The

name, location, and sponsorship should be disclosed.

Drug Information Centre can provide information regarding drugs, their toxicity and

treatment round the clock. In the absence of any available treatment, the centers give only

first aid advice and recommend symptomatic treatment. Answering enquiry, or dealing withrequest or information forms an integral part of the daily routine for all pharmacists. For this

purpose Drug information request forms are available in the DIC, which is filled up by the

pharmacist who is in charge.

REFERENCE

1. The Text Book Of Clinical Pharmacy Practice by G.Parthasarathi, Karin Nyfort

Hansen, Milap C Nahata, 267281.

2. Comprehensive Pharmacy by Leon Shargel, Seventh Edition, 694-710


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EXERCISE NO: 1 DATE: 03/03/13

QUERY

Available dosage forms of rabeprazole and its adverse drug reactions?

ANSWER

1. Rabeprazole available dosage forms are tablet, injections and vials2. The adverse drug reactions include

REFERENCE

1. Gastroesophageal Reflux Disease, Barbara G.; DiPiro, Joseph T.;

Schwinghammer, Terry L.; Hamilton, Cindy W. Pharmacotherapy Handbook,6th Edition, McGraw-Hill Publishers, 203-207.

2. Micromedex, www.medscape.com.


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QUERY

Indication, content and available dose of Belar Forte tablet?

ANSWER

1. Indications are allergic and inflammatory disorders and congenital adrenalhyperplasia.

2. Content is Betamethasone3. Available doses are 0.5mg, 1mg.

REFERENCE

1. Psoriasis, Barbara G.; DiPiro, Joseph T.; Schwinghammer, Terry L.; Hamilton,

Cindy W. Pharmacotherapy A physiological Approach, 7th Edition, McGraw-

Hill Publishers, 1604

2. http://mims.com

3. http://Micromedex.com,


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QUERY

What are the adverse effects of the insulin injections?

ANSWER

Possible adverse effects of the insulin injections include hypoglycemia, insulin

resistance, lipoatrophy, hypokalaemia, blurred vision.

REFERENCE

1. Diabetes Mellitus, Barbara G.; DiPiro, Joseph T.; Schwinghammer, Terry L.;

Hamilton, Cindy W. Pharmacotherapy A physiological Approach, 7th Edition,

McGraw-Hill Publishers, 1216

2. http://mims.com

3. http://Micromedex.com


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10 CLINICAL PHARMACY


EXERCISE NO: 4 DATE: 18/ 07/ 13

QUERY

How use the Rotahaler ?

ANSWER1. Hold rotahaler vertically and put capsule into square hole. Make sure top of rotacap

is level with top of hole.

2. Hold rotahaler horizontally, twist barrel sharply forwards and backwards. This

splits capsule into two.

3. Breathe out gently. Keep rotahaler level and put mouthpiece between lips and teeth

and breathe in the powder quickly and deeply

4. Remove rotahaler from mouth and hold breath for about 10 seconds

5. If any powder is left repeat breathe in.6. Open the Rotahaler and discard the empty capsule.

REFERNCE

1. Asthma, Barbara G.; DiPiro, Joseph T.; Schwinghammer, Terry L.; Hamilton,

Cindy W. Pharmacotherapy A physiological Approach, 7th Edition, McGraw-Hill

Publishers, 472

2. http://nartc.com


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PATIENT COUNSELLING

INTRODUCTION

Safe and effective drug therapy depends on patients being well informed about their

medication. In India health care is provided at primary, secondary and tertiary levels. Lack of

information may lead to therapeutic failure, adverse effect, additional expenditure on

investigation and treatment or even hospitalization. Many drugs problem and their

consequences can be addressed by patient education.

DEFINITION

Counseling is a special form of interpersonal communication in which feelings, thoughts

and attitudes are expressed, explored and clarified.

OBJECTIVES OF PATIENT COUNSELING

To provide correct information about drugs to the patient.

It can support and help the patient to regain a sense of competence and skill at

times of crisis.

It can help to educate the patient about vaccination and immunization

procedures on mass sterilization issues, contraception, programme etc.

Patient counseling refers to the process of providing information, advice and

assistance to help patient to use their medication appropriately.

During counseling, the pharmacist should assess their patient understanding

about his or her illness and its treatment and provide advice to information

which will assist the patient to take their medication in the most safe and

effective manner.

It provides realistic action suitable for different clients and circumstances.

It helps to enhance determination, self-confidence and improve family and

community relationship and quality of life.

AIMS OF PATIENT COUNSELING

Effective patient counseling aim to produce the following results

Better patient understanding of their illness and the role of medication in its

treatment

Improved medication in its adherence

More effective drug treatment

Reduced incidence of adverse effect and unnecessary health care costs.

Improved quality of life for patient

Better strategies to deals with medication related adverse effects.

Improved professional support between patient and pharmacist.


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STEPS INVOLVED IN PATIENT COUNSELING

Counseling is a two way communication process and interaction between the patient and

the pharmacist and is essential for counseling to be effective.

1. PREPARING FOR THE SESSIONThe success of counseling depends upon the knowledge and skill of the counselor. The

pharmacist should know as much as possible about the patient and his/her treatment details.

In hospitals it can be possible by referring the patient case notes. In community pharmacy

setting, source of information includes the patient and their prescription and in some cases a

record of previous dispensing for the patient. If the patient is receiving a medication which is

unfamiliar to the pharmacist then a drug information reference should be consulted before

counseling commences.

In some cases if the patient is in a hurry or in pain, is non-communicative, it is verydifficult to counsel the patient effectively. In this situation, the aims of counseling may need

to be modified or with the patients agreement the session may be postponed to a later date.

2. OPENING THE SESSIONThe first phase of counseling is used for information gathering. The pharmacist should

introduce himself or herself to the patient and greet them by name. It is best to use titles such

as Mr., Ms., and then switch to the first name. The pharmacist should identify the purpose of

the session very clearly.

For example:

Hello Mr. Unni my name is Vikas and I am a pharmacist. I would to tell you about your

medication. Do you have few minutes to spend with me?

3. COUNSELING CONTENTThe counseling content is considered to be the heart of the counseling session. During this

step the pharmacist explain to the patient about his or her medication and treatment regimen.

Topic commonly covered includes,

Name and strength of the medication

Expected duration of treatment

Expected benefits of treatment

Possible adverse effects

Possible medication or dietary interaction

Advice on correct storage

Information which is given should be tailored to the individual patient. It is important not

to jump to conclusion about why a particular medication has been prescribed. Sometimes the


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patient family members may visit the pharmacy to collect the medication. They should be

given suitable advice after gathering information such as their relationship with the patient

and their awareness of the patient disease and medication history.

4. CLOSING THE SESSIONBefore closing the session pharmacist or counselor should check the patients

understanding. This can be assessed by feedback questioning. We should finish the session

by asking the patient Do you have any question? Before final closure if time permits

summaries the main points in a logical order. Counselor should give their telephone number

to encourage the patient to make contact if they need further advice or information.

BARRIERS

The common Barriers involved in the patient counseling are,

Patient based barriers

System based barriers

Provider based barriers

1. Patient Related BarriersIt includes;

Culture

Language

Hearing

Vision

Mental status

Gender

Limited patient availability

2. System Based BarriersIt includes;

Lack of space

Lack of staff

3. Provider Based BarriersIt includes;

Lack of knowledge

Lack of time

Lack of training

Lack of confidence

Lack of interest


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STRATEGIES TO OVERCOME BARRIERS

To conduct an effective patient counseling, the common requirements are

(1)Availability of pharmacist

(2)

Creating an atmosphere for patient(3)Developing an effective approach to patient counseling

(4)Approach to provide optimum information

To overcome the barrier like lack of confidence is prepared prior to counseling. For

effective counseling communication skill is very important. The communicating process was

carried out either by verbal and nonverbal communication method.

REFERENCES

1 The Pharmaceutical Practice by AJ Winfield and Richards: 4445

2 A Text Book of Clinical Pharmacy Practice by Parthasarathi: 4349.


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EXERCISE NO: 1 DATE: 05.02.13

PATIENT COUNSELING FOR ACUTE GASTROENTERITIS

AIM

To counsel the patient about the disease

COUNSELING ABOUT THE DISEASE

AGE is the inflammatory disorder of the stomach and intestine.

Affect the body through direct invasion and by endotoxin being released by

the organism

Ingestion of fecal contaminated food and water.

Pain or tenderness of the abdomen is then felt by the patient.

Mild diarrhoea - 2-3 stool, bowel sound, fluid and electrolyte imbalance and

hypernatremia.

COUNSELLING ABOUT LIFE STYLE MODIFICATION

Uncontaminated water and food

Breast feeding at hygienic place

Avoid milk and milk products.

Bland, easy-to-digest foods, such as toast, rice, bananas and potatoes.

Give boiled and cooled foods

Avoid giving raw food items

Clean the area and objects were baby playing


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PATIENT COUNSELING FOR HYPOTHYROIDISM

AIM

To counsel the patient about the disease.


Main course is thyroid gland failure

Causes include chronic autoimmune thyroiditis (Hashimoto's disease),

iatrogenic hypothyroidism, iodine deficiency, enzyme defects, thyroidhypoplasia, and goitrogens.

Adult manifestations of hypothyroidism include dry skin, cold intolerance,

weight gain, constipation, weakness, lethargy, fatigue, muscle cramps,

myalgia, stiffness, and loss of ambition or energy. In children, thyroid

hormone deficiency may manifest as growth retardation. Physical signs include coarse skin and hair, cold or dry skin, periorbital

puffiness, bradycardia, and slowed or hoarse speech. Objective weakness

(with proximal muscles being affected more than distal muscles) and slow

relaxation of deep tendon reflexes are common


Take iodine containing foods

Iodinated salt, sea vegetables, cows milk, strawberries.

Take high fibrous foods to resolve constipation

Reduce sodium intake.


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PATIENT COUNSELING FOR ULCERATIVE COLITIS

AIM

To counsel the patient about the disease.

COUNSELING ABOUT DISEASE

Ulcerative colitis is confined to the colon and rectum, the mucosa and the sub

mucosa. The patient with toxic mega colon usually has a high fever, tachycardia,

distended abdomen, elevated white blood cell count, and a dilated colon.

The risk of colonic carcinoma is much greater in patients with ulcerative colitis

as compared with the general population.

Ocular complications iritis, episcleritis, and conjunctivitis occur, dermatologic or

mucosal complications are erythema nodosum, pyoderma gangrenosum,

aphthous stomatitis).

COUNSELING ABOUT LIFE STYLE MODIFICATION

Eat small amounts of food throughout the day.

Make sure to chew food very well.

Drink plenty of water.

Avoid high-fiber foods (bran, beans, nuts, seeds, and popcorn).

Avoid fatty, greasy or fried foods and sauces (butter, margarine, and

heavy cream).

Avoid all things that would be bowel irritant (coffee, tea, colas, chocolates),

alcohol, all carbonated beverages, vinegar etc.

Avoid stress and highly emotional situations.

Avoid all additives, flavorings, colorings, baking powder.


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PATIENT COUNSELING FOR COPD

AIM

To counsel the patient about the disease


Chronic obstructive pulmonary disease (COPD) is defined as a disease

characterized by progressive airflow limitation that is not fully reversible.

The most common conditions comprising COPD are chronic bronchitis

and emphysema.

Chronic bronchitis is associated with chronic or recurrent excess mucus

secretion into the bronchial tree with cough that occurs on most days for at

least 3 months of the year for at least 2 consecutive years when other

causes of cough have been excluded.

Emphysema is defined as abnormal, permanent enlargement of the

airspaces distal to the terminal bronchioles, accompanied by destruction of

their walls, but without obvious fibrosis.

Initial symptoms of COPD include chronic cough and sputum production;

patients may have these symptoms for several years before dyspnoea

develops.

Smoking cessation is the most effective strategy to reduce the risk of

developing COPD.


Vitamins E and C and -carotene containing foods

Avoid close contact with people who have respiratory infection.

Avoid exposure to environmental irritants.

Avoid excessive heat, cold and high altitudes.

Two 15-minute intervals of pleasurable walking or cycling.


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INTERPRETATION OF LABORATORY DATA

INTRODUCTION

Laboratory test results are used to investigate potential problems with a patients

anatomy or physiology. The pharmacists usually monitor laboratory tests to:

Assess the therapeutic and adverse effects of a drug

Determine the proper drug use

Assess the need for additional or alternate drug therapy

Prevent test misinterpretation resulting from drug interference

Normal laboratory test results fall within a predetermined range of values, and abnormal

values fall outside that range. The results of most laboratory tests are reported with areference range-a numerical range of results for that investigation when performed for a

healthy subject (in the absence of significant disease). The values outside the normal range

may not necessarily indicate disease or the need for the treatment. Conversely, if a result falls

within the quoted reference range this does not necessarily guarantee the absence of disease

or abnormal organ function. For these reasons it is important that a clinical pharmacist should

interpret results with reference to the clinical status of the patient and other relevant

information. A clinical pharmacist must be able to interpret lab data for a number of reasons:

Laboratory data can provide guidance regarding the appropriateness of the

patients current drug therapy. The results may suggest that a particular drug is not

appropriate for the patient and should therefore to be discontinued or avoided

(e.g.: NSAID for a patient with severe renal impairment.

It can also be used as a guide to determine the adequacy of drug response.

The measurement of blood glucose parameters when assessing the effectiveness of

insulin treatment.

Monitoring for the efficacy of treatment.

Laboratory test can also be used to check for signs of serious drug toxicities that

may be reflected by abnormal biochemical or hematological parameters or

elevated liver function tests.

RATIONALE FOR ORDERING LABORATORY TEST

Laboratory test are performed with the expectation of that result will help practitioner

or patient in the following;

Discovery of occult disease

Confirming the suspected diagnosis after signs and symptoms appears

Differential diagnosis of a disease

Determining the stage or activity level of the disease


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Determining the recurrence of disease

Evaluating the effectiveness of therapy

Laboratory test can also be subdivided in to discretionary and screening test.

Screening test is performed without clinical indication either on hospitalized patient or

healthy outpatient for early or preventive diagnostic measure. Screening tests are more

valuable when the disease is common salient and treatable.

Discretionary investigation could include items 2-6 the test above. There is

performed discretion of the prescriber based on the provisional diagnosis or proposal for

treatment. The lab investigation involve the estimation of the following samples

Urine

Sputum

Blood

CSF Faeces

Peritoneal fluid

Laboratory data can be classified as following based on the organs whose function are

analyzed

Hematological test

Liver function test

Renal function test

Cardiac function test Stool microscopy Culture sensitivity

Pulmonary function test

Thyroid function test

HAEMATOLOGICAL TEST

Haematology provides information about cellular components and non-cellular

component. The routine test include

RBC count , WBC count, Hemoglobin level, Hematocrit

RBC indices :- MCV, MCH, MCHC

Reticulocyte count

ESR

Platelet count

Bleeding time

Clotting time

Prothrombin time


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LIVER FUNCTION TEST

It helps in measuring hepatic or biliary inflammation and also helps to assist liver

synthetic and functional capabilities include albumin, globulin, and prothrombin time. Liver

function tests help to find out cholestatic disease through measurement of alkaline phosphate

ALP and gammaglutaryl transpeptidase (GGT). Hepatocellular injury can also rule out by

measuring aspartate aminotransferase (AST) and alanine amino transferase (ALT).

RENAL FUNCTION TESTS

Renal function test are used to measure the functioning capacity of kidney and also for

measuring GFR. The tests include BUN, Serum creatinine. By using creatinine clearance we

can adjust dose, assessment of acute and chronic renal failure, glomerular nephritis, nephritic

syndrome etc.

CARDIAC ENZYMES

These tests are specific to evaluate unstable angina, Myocardial infarction and ischemic

heart disease. To assess the cardiac function test such as biochemical tests ECG and non-

invasive imaging technique can be done. The cardiac enzymes are CKMB and LDH (lactate

dehydrogenase). C-reactive protein and amyloid A protein are also use to detect cardiac

problems.

CEREBROSPINAL FLUID

CSF analysis is done to find any infections. In CSF analysis protein, glucose, chlorides

are measuring. Viral infections also affect CSF.

STOOL EXAMINATION

Stool microscopy can be done in case of any blood tinch in stool or faeces occult.

CULTURE SENSITIVITY

The samples are cultured and the sensitivity and resistants pattern of microorganism can

be done. It will help to appropriate therapy.


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PULMONARY FUNCTION TEST

This test useful in case of respiratory diseases it will helps in the diagnosis, evaluation

and monitoring of disease. By performing PFT lung damage, obstruction and restrictive

disease can be detected. PFT include lung volume and lung flow tests. Lung volume tests are

tidal volume, vital capacity, total lung capacity, residual volume etc. The later include FEV,

FEV1, FVC, and PEFR.

THYROID FUNCTION TESTS

This test is used to find out hypothyroidism and hyperthyroidism. Hypothyroidism may

be due to defect in thyroid, in pituitary or hypothalamus. By measuring the amount of T3, T4,

TSH can differentially diagnoses the severity.

Thyroid function tests include: - measurement of T3AND T4. Evaluate the integrity of

hypothalamus, pituitary, Thyroid axis. Assess inherent thyroid gland function detect

antibodies.


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I. LABORATORY ASSESSMENT OF ANEMIA

Anemia can be defined as a decrease in either the RBC count or Hb count. Patient with

mild anemia are often asymptomatic but severely symptomatic patients manifest shortness of

breath, tachycardia, and palpitation even at rest.

Patient with anemia (RBCHb)

Review RBC indices, especially MCV

MCV> 100fl MCV:81-99 fl MCV 80 fl

Macrocytic anemia Normocytic anemia Microcytic anemia

Possible causes:

Vit B12 deficiency

Folic acid deficiency

Drug induced bone

marrow toxicity

Possible causes:

Acute blood loss anemia

Hemolytic anemia

Anemia of chronic disease

Possible causes:

Iron-deficiency

anemia

MACROCYTIC ANEMIA

It is associated with abnormally enlarged erythrocytes. The two most common causes

are vit-B12 and folic acid deficiency. Drugs that cause macrocytic anemia mainly interfere

with proper utilization, absorption, and metabolism of other vitamins.

MICROCYTIC ANEMIA

It is associated with abnormally small erythrocytes. Iron deficiency is the primary cause

of microcytic anemia. Iron is necessary for the hemoglobin synthesis. Serum ferritin

concentration reflects total body iron stores and can be used for evaluating patients with

microcytic anemia.

Iron deficiency is usually due to:

In adequate dietary intake

Increased iron requirement In pregnancy


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NORMOCYTIC ANEMIA

Both the MCU and MCHC are within the reference range

Three causes are;

Acute blood loss anemia: patients with acute hemorrhage can have a

dramatic drop in the RBC count

Hemolytic anemia: if hemolysis is rapid and extensive, severe anemia can

develop RBC indices remain unchanged. A specialized test called anti

globulin test (coombs test) is used.

Test Vit-B12deficiency

anemia

Folic aciddeficiency

anemia

Iron

deficiency

anemia

Hemolyticanemia

RBC

Hgb

Hct

MCV

MCH

MCHC

Reticulocytes

or or or

Serum vit

B12

Serum-folic

acid

Serum-iron

&ferritin

Antiglobulin

test

Positive


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EXERCISE NO: 1 DATE:20/02/13


AIM

To analyze and interpret the lab data of a male patient presented with Anemia

SUBJECTIVE EVIDENCE

Patient was complaining about generalized weakness

OBJECTIVE EVIDENCE

The hematology report shows the following;

Hb: 5.0 gm/dl

TRBC: 3.37 mil/cumm

MCV: 56 fl

MCH: 15 pg

MCHC: 26 %

PCV: 19%

RDW: 18.3%

INTERPRETATION

Based on subjective evidence like generalized weakness; physician suspect that the patient

is aneamic. Also physical examination shows pallor was present.

Based on the objective evidence such as decreased Hb, MCV, MCH, and MCHC;

indicating the patient suffering from iron deficiency aneamia. The haemoglobin level was

decreased (5.0 gm/dl), it also confirm IDA.

From the subjective and objective evidence it was confirmed that patient was suffering

from iron deficiency anaemia. Objective evidence is more support to confirm the diagnosis.

In this patient MCV is decreased. It is a strong supportive evidence for IDA. Decreased

MCH shows the pigmentation of RBC. It is hypochromic (less pigmented) than the normal

RBC.


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HAEMOGLOBIN

The normal level of hemoglobin in male is 14-18 g/dl. The patient hemoglobin level is

5.0 gm. /dl; the decreased hemoglobin level shows the decreased oxygen carrying capacity of

cell. This decreased capacity will lead to hypoxia. The drastic decrease in oxygen carrying

capacity will cause further complication. It was found that increase in hemoglobin level seen

in patients who are living in high altitude.

HEMATOCRIT (Hct) OR PACKED CELL VOLUME (PCV)

Normal range: 42-52% for males and 37-47% for females.

Hct is the percentage volume of blood that is composed of erythrocytes.The Hct value is

usually 3 times than Hb value. Lowered Hct may be due to significant hemorrhage, anemia,

over hydration.

High Hct values may indicate polycythemia vera or dehydration. PCV value is

decreased in iron deficiency anemia.

RBC INDICES

Mean cell volume (MCV) : - (82-98 fl)

MCV is the average volume of RBC. MCV can be finding out from RBC. Abnormally

small cells (with decreased MCV) are called microcytic. The most common cause of

decreased MCV and microcytisis is iron deficiency. Decreased MCV indicate abnormality in

the Hb synthesis. MCV also falsely increased in hyperglycemia. Both folate deficiency and

vitamin B12 causes increase in MCV.

Mean cell hemoglobin (MCH) : - (27-33pg/cell)

MCH is the percent volume of Hb per RBC

MCH= Hg b/ RBC

The MCH is decreased in iron deficiency anemia and also decreased in MCH will cause

the diminishing in the cell color result in hypochromic cell.

MCH is increased in both vit B12 and folate deficiency anemia. It is not affecting MCH

in hemolytic anemia.


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Mean cell hemoglobin concentration (MCHC): (31-35 gm/dl)

MCHC can be estimated by Hgb / Hct

MCHC is routinely low in iron deficiency anaemia. MCHC also decreased in

decrease Hb synthesis.

MCHC is increased in anaemia of chronic disease. MCHC is normal in vit B12

deficiency and folic acid deficiency.

DIAGNOSIS

The patient diagnosed as iron deficiency anemia.

PLANNING

The test done in this patient is suggestive of iron deficiency anemia. The treatment option

based to the type of anemia. The best option in this patient is oral iron preparation ferrous

sulphate 200 mg TID and packed cell.

CONCLUSION

From the subjective and objective evidence pointing out the patient suffering from iron

deficiency anemia (microcytic hypochromic anemia)


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II. LABORATORY ASSESSMENT OF LIVER FUNCTION TEST

Investigation of liver disease often begins with obtaining a panel of liver tests generally

referred to as the liver function test panel or liver functions tests (LFTs). This level may varyslightly between hospitals and labs but generally includes the Aminotransferase (aspartate

aminotransferase (AST) and Alanine aminotransferase (ALT)), Bilirubin, Alkaline

phosphatase, and Albumin).

TEST FOR SYNTHETIC LIVER FUNCTION

The function of the liver is to synthesize proteins that circulate in the blood, including

albumin and clotting proteins. Measurement of the levels of these proteins in the blood

provides a direct reflection of the ability of the liver to synthesize them. Tests of synthetic

function are not sensitive to low levels of liver damage or dysfunction. Inadequate protein

synthetic function is mainly limited to hepatic cirrhosis, scarring of the liver that can result

from years of alcohol abuse, inflammation, or massive liver damage. (E.g. due to alcoholic

liver disease, severe viral hepatitis or potentially lethal toxin ingestion). In these situations,

measuring synthetic function may be useful in determining prognosis by reflecting the degree

of hepatic failure. The most commonly used tests of protein synthetic function are serum

albumin levels and prothrombin time.

1.

ALBUMINS

Normal range: 3.5-5.5 grams/dl

Albumin is a major plasma protein that is involved in maintaining plasma oncotic

pressure and the binding and transport of numerous hormones, anions, drugs, fatty acid. The

normal serum half-life of albumin is about 20 days. Because of albumins long half life,

serum albumin measurements are slow to fall after the onset of hepatic dysfunction (e.g.:

complete cessation of albumin production results in only 20% decrease in serum

concentration after 8 days). For this reason, levels are often normal in acute viral hepatitis or

drug related hepatotoxicity. Alternatively albumin is commonly reduced in patients withchronic synthetic dysfunction due to cirrhosis.

Hypoalbuminemia (< 2- 2.5 g/dl)

At very low concentrations, patients can develop peripheral edema, ascites, or pulmonary

edema. Low albumin concentrations affect the interpretation of total serum calcium and

concentrations of drugs that are highly protein bound (eg: phenytoin and salicylates).


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Hyper albuminemia (> 3 g/dl)

It is seen in patient with marked dehydration, where it is associated with concurrent

elevations in blood urea nitrogen and hematocit. Patients taking anabolic steroids may

demonstrate truly increased albumin concentrations, but those on heparin or ampicillin may

have falsely elevated results with some assays. Hyperalbuminemia is asymptomatic.

2. PREALBUMIN Normal range: 19.5 35.8 mg/ml

Prealbumin is similar to albumin in several respects: it is synthesized primarily by the

liver and is involved in the binding and transport of various solutes (thyroxin and retinol) and

it is affected by similar factors that affect albumin levels. The primary difference between thetwo proteins is that prealbumin has a short half-life (2 day than albumin, compared to 20 days

for albumin) and a smaller body pool than albumin.

3. INTERNATIONAL NORMALIZED RATIO (INR) AND PROTHROMBINTIME

: INR: 0.9-1.1

PT: 11.1-13.1 sec

PT Normal range: 11.1-13.1 sec

These two tests measure the speed of a set of reaction in the extrinsic pathway of the

coagulation cascade. A coagulation deficit correlates with prothrombin time. Either hepatic

impairment or vitamin K deficiency may lead to a deficiency in activated coagulation factor

with subsequent prolongation of PT/INR. Both synthetic failure and vitamin K deficiency

may also cause prolongation of activated partial thromboplastin time but to a lesser degree

than PT/INR. The PT/INR is prolonged due to malabsorption, warfarin administration, or the

absence of vitamin K in diet.


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TESTS ASSOCIATED WITH EXCRETORY LIVER FUNCTION AND

CHOLESTASIS

Laboratory tests do not distinguish between intra- and extrahepatic cholestasis. This

distinction is usually made radiographically. Laboratory abnormalities primarily associated

with cholestasis include elevation of alkaline phosphatase (ALP, 5-nucleotidase, -glutamyl

transpeptidase (GGTP), and bilirubin.

1. ALKALINE PHOSPHATASE (ALP) Normal range: 30-120 units/ml

Alkaline phosphatase refers to a group of enzymes whose exact function remains

unknown. These enzymes are found in many body tissues including the liver, bone, small

intestine, kidney, placenta, and leukocyte. Normal ALP concentration may vary with age. In

children and adolescents, elevated ALP concentrations result from bone growth, which maybe associated with elevations as high as 3 times the adult normal range. Clinically ALP

elevation is associated with cholestatic disorder. ALP concentrations more than 4 times

normal suggest a cholestatic disorder. If ALP is elevated with elevated 5nucleotidase or

GGTP indicates that the source is primarily hepatic. With normal 5 nucleotidase or GGTP, it

is nonhepatic cause. ALP is increased in pregnancy due to placental ALP. Non hepatic causes

of elevated ALP include bone disorders (eg: healing fractures, osteomalacia),

hyperthyroidism, hyperparathyroidism, diabetic mellitus, renal failure. ALP concentration

can be lowered by a number of conditions including, hypothyroidism, hypophosphatemia,

pernicious anemia.

2. 5- NUCLEOTIDASE Normal range: 0-11 units/L

5- nucleotidase is found in many tissue (including liver, brain, heart, blood vessels),

serum 5- nucleotidase is elevated only in hepatic diseases.

3. -GLUTAMYL TRANSPEPTIDASE Normal range: 1-94 units/ L

Glutamyl transpeptidase (GGTP or GGT), a biliary excretory enzyme, can also help

determine whether an elevated ALP is of hepatic injury. It is found in kidney, pancreas,

spleen, heart, brain, liver and seminal vesicles. GGTP concentration is elevated in alcoholic

liver disease, pancreatic diseases, MI, severe COPD, diabetes, kidney disease.


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1. ASPARTATE AMINOTRANSFERASE (AST) Normal AST: 80IU/L.

AST (aspartate aminotransferase) is an enzyme found in high amounts in liver and less

amount in heart muscle skeletal muscle cells, kidney, brain, lungs, intestine.

An increase in ALT levels may be due to:

Acute pancreatitis

Cirrhosis

Death of liver tissue (liver necrosis)

Hepatitis (viral, autoimmune)

Lack of blood flow to the liver (liver ischemia)

Liver disease Liver tumour

An increase in AST levels may indicate:

Acute haemolytic anaemia

Acute pancreatitis

Acute renal failure

Cirrhosis

Heart attack

Hepatitis

2. LACTATE DEHYDROGENASE (LDH) Normal range:-100-225 IU/L

LDH is found in most human tissues but primarily in myocardium, liver, skeletal

muscle, brain, kidney and RBCs. LDH has 5 isoenzymes and type 5(LDH5) is corresponds to

liver disease. Although LDH5 is less sensitive to liver disease than the amino transferase,

elevated concentration occurring patients with hepatitis, biliary obstruction, meta stable liverdisease or exacerbation of cirrhosis.

3. ALPHA-1 ANTITRYPSINAlpha-1 antitrypsin is a laboratory test to measure the amount of alpha-1 antitrypsin

(A1AT) in your blood. It helps in identifying emphysema in adults and liver disease

(cirrhosis) in children and adults. If there is no A1AT, certain digestive proteins (enzymes)

released by white blood cells and cause widespread damage in the lungs and liver.


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TEST FOR DETOXIFICATION

HEPATIC ENCEPHALOPATHY

Diffused metabolic dysfunction of brain occurs due to acute or chronic liver failure.

Ammonia is formed by catabolism of protien within the gut lumen by conversion of serum

glutamine into ammonia by enterocyte in intestine and enters the blood from intestine. Liver

removes >90% of ammonia by first pass metabolism. This may effect in liver failure.

1. AMMONIA Normal range: 10-80mg/Dl or 17-41mol/L (Adults & pediatrics)

New born: 90-150 g/dl

In patients with cirrhosis, ammonia concentration in serum or CSF may increase.

Ammonia levels are used primarily to evaluate patients with hepatic encephalopathy or coma.

Ammonia conc. can be elevated in patients:

With inborn disorders of urea cycle

With Reyes syndrome

On very high protein diet

TESTS FOR HEPATITIS

Test for the Hepatitis A Virus (HAV), measure the HAV antibodies of either IgM or IgG

types. These antibodies are present at the onset of jaundice and usually resolve over 2-3

months. In type B Hepatitis; the hepatitis B virus (HBV) is a DNA virus. This virus is

surrounded by a protein called the surface antigen (HBsAg). Inside this coat, a core (HBcAg)

protein coat surrounds the DNA & DNA polymerase.

Another protein that seems to be in this virus is the e-antigen (HBeAg). In response to

infection with hepatitis B virus, the body produces antibodies to the antigen, antisurface

antigen (anti-HBS), anticore antigen (anti-HBC) and anti-e antigen (anti-HBE). All of theseantibodies can detect in clinical laboratory. In Hepatitis C, there is elevated LFTs for 6

months. ALT and AST values commonly in 60-100 IU/L range. Chronic active Hepatitis C

can be confirmed by a liver biopsy.


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AIM

To analyze and interpret the lab data of a patient presented with viral hepatitis A.

SUBJECTIVE EVIDENCE

Patient complains of fever and vomiting since one day. Also complains of

discoloration of skin and eye since one day.

OBJECTIVE EVIDENCE

Liver enzymes estimation shows as following:

AST - 4030 iu/l

ALT4360 iu/l

Albumin - (+++) present

Bilirubin:

Total -8mg/dl

Direct - 5.6mg/dl

HAV IGM antibody -1.68(positive)

INTERPRETATION

The patient has a history of viral fever. Normal direct bilirubin level is 0.1-0.3. Elevatedbilirubin implies hepatic disease that interferes with the excretion of bilirubin from the

hepatocytes or clearance of bile from the liver. It is also found in other conditions like

hemolysis or infective RBC production.

Hepatitis is a term that technically refers to a histologic pattern of inflammation of

hepatocytes. The laboratory reflection of hepatitis is a hepatocellular injury pattern which is

marked primarily by elevated aminotrasferases. Here both the aminotransferases ie, AST and

ALT are elevated. Presence of HAV IgM antibody confirms the viral hepatitis A. The

patients history of viral fever again reinforced the confirmation.


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PLANNING

The liver function test report shows viral hepatitis A in this patient. The tests like AST,

ALT are done. The test for viral hepatitis A ie, HAV IgM antibody test is done which

confirmed the disease as viral hepatitis A. By using this laboratory parameter treatment can

be planned for this patient.

CONCLUSION

Interpretation of liver function test of patient diagnosed as viral hepatitis A.


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III. LABORATORY ASSESSMENT OF RENAL FUNCTION TEST

Kidney plays a vital role in the body homeostasis with their ability to excrete and

reabsorb various exogenous and endogenous substances selectively. The functional unit ofkidney consists of one million nephrons. Glomerulus allows substance with molecular weight

up to 40,000. So this prevents passage of plasma proteins and RBC. Kidney filters about

180L of fluid each day, of this only 1.5L is excreted as urine.

INDICATORS OF RENAL FUNCTION

1. SERUM CREATININE Normal range: For adults: 0.7-1.5mg/dl

For childrens: 0.2-0.7mg/dl

Creatinine and its precursor creatinine are non-protein nitrogenous of the bloods. After

synthesis in the liver; creatinine diffuses in to the blood stream and taken up by muscle cells.

Some of them convert in to creatinine phosphate. The daily production of creatinine is about

2% total body creatinine, which remains constant of muscle and is not significantly changed.

Causes of changes in serum creatinine include following:

A rise in serum creatinine (S.cr) indicates worsening of renal function

Renal dysfunction, urinary tract obstruction always decrease excretion

In addition drugs such as cimetidine, triametrine, amiloride, spirinolactone, inhibit

tubular secretion of creatinine.

Other factor like muscle mass, gender, period of time that has elapsed after the insult

also influence the renal function

2. CRETININE CLEARENCE Normal:-90-140ml/min

It represents the rate at which creatinine is removed from the blood by the kidneys,

roughly approximates GFR. Calculation requires the knowledge of urinary creatinine

excretion (usually over 24hr) and concurrent serum creatinine levels.

ClCR ClCR=Creatinine clearance in ml/min

U= Conc. of creatinine in urine,


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V=Urine volume ml/min,

P=Serum creatinine conc.

BSA=Patients body surface area

BSA (m2) =

Estimation of creatinine clearance without urine collection

One method of estimation uses the Cockroft & Gault, which is based on body weight, age and

gender.

ClCR=

In females, the result has traditionally been multiplied by 0.85.

3. BLOOD UREA NITROGEN

Normal range: 8-20mg/dl

Blood urea nitrogen (BUN) is less sensitive indicators of renal function. It may be

elevated due to dehydration, blood loss, shock, severe heart failure, high protein diet. But it

elevated in the case of severe hypertension, Glomerular nephritis, tubular necrosis,

pyelonephritis, polycystic kidney etc.

4.

SERUM ELECTROLYTES

a. SODIUM

Normal range: 135-145mmol/lit

The principal role of Na is to regulation of serum osmolality, fluid& acid base balance.

Kidneys are `primary organ responsible for the controlling body Na &water. Glomeruli filter

about 180L of water and 600g of sodium per day. Less than 2L of water and 0.1-40gm of

sodium end up in the urine. Aldosterone and ADH are mainly responsible for control of water

and Na acting at distal convoluted tubule and collecting duct.


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b. POTASSIUM Normal range:3.5-5.0mmol/L

The kidney is the primary organ involved in the control and elimination of potassium.

Potassium is freely filtered at the glomerulus and almost completely absorb in the tubule.

Aldosterone is important factor acting at the distal tubule increase potassium secretion.

Presence of anions in the distal tubules can increase potassium loss.

5. URINALYSISUrinalysis are used to search for evaluate renal and non-renal problem.

a. PROTEIN Normal range: 0-1 150mg/day

Abnormal permeability of the glomerular limiting membrane allows large quantities of

albumin to enter the urine.

Little proteinuria (3g/day): Lupus nephritis, chronic glomerulonephritis.

b. PH Normal range: 4.5-8.0

In general acidic urine detects bacterial colonization. Alkaline urine may be seen with

urinary tract infection caused by urea splitting bacteria such as Proteus mirabilis, tubular

defects causing decreased net tubular hydrogen ion secretion.

c. SPECIFIC GRAVITY

Normal range 1.010-1.025

Specific gravity determination helps to determine kidneys concentrating ability.


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AIM

To analyze and interpret the lab data of a patient presented with chronic renal

failure.

SUBJECTIVE EVIDENCE

The patient complaining of pedal oedema for 10days .Patient is known case of

hypertension and acute glomerular nephritis.He had puffiness of face, anorexia,

dyspepsia and nocturia.

OBJECTIVE EVIDENCE

Blood urea: 85mg/dl

S.creatinine: 5.5mg/dl

S.Ca2+: 7.2 mg/dl S.K+: 3.4 mEq/L

INTERPRETATION

Normal level of serum creatinine is 0.6-1.6mg/dl.A rise in S.cr almost always indicates

worsening of renal function. Renal dysfunction, urinary tract obstruction always decreases

excretion of drugs such as cimetidine, triametrine, amiloride, spiranolactone, in-habits tubular

secretion of creatinine.

Normal blood urea nitrogen (BUN) is 15-45. BUN is less sensitive indicators of renal

function. It may be elevated due to dehydration, blood loss,shock,severe heart failure, high

protein diet. But it elevated in the case of severe hypertension Glomerular nephritis tubular

necrosis pyelonephritis and polycystic kidney.

Normal serum potassium is 4.5-5.5meq/l.Here it is reduced. Normal serum calcium is 8.5-

10.5mg/dl. Here both of these ions are reduced which also confirms the electrolyte

imbalance.


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IV. LABORATORY ASSESSMENT OFCARDIAC FUNCTION TEST

LABORATORY TESTS USED IN ACD

Three Criteria for the diagnosis of acute myocardial infarction (AMI) are clinical

presentation, electrocardiography and elevated biochemical markers. Clinical presentation

will not distinguish among unstable angina (UA), NSTEMI, and STEMI. ECG differentiates

between NSTEMI and STEMI. Cardiac-specific biochemical markers are used to

differentiate between UA and MI.

BIOCHEMICAL MARKERS

Criteria of ideal biochemical marker for the diagnosis of acute coronary syndrome include:

High specificity High sensitivity

Rapidly released into the blood stream after myocardial injury.

Persists for sufficient time.

Measured level of marker is directly proportional to the myocardial injury.

Assay technique should be available, easy to perform, inexpensive, rapid

1. CARIAC SPECIFIC TROPONIN I AND CARDIAC SPECIFIC TROPONIN T Diagnostic level: Troponin T (Tn T)


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2. CREATIN KINASE Normal range: Males-40-200 iu/l

Normal range: Females-35-150 iu/l

CK is found in skeletal muscle, myocardium, and brain. It is an enzyme that stimulates

the transfer of high energy phosphate groups. Circulating CK is directly proportional to the

individuals muscle mass. CK level rise 4-8 hrs after the onset of chest pain associated with

AMI, peak in 24 hrs and return to normal in 3-4 days

Causes of elevated CK levels:

Cardiac causes (myocarditis, pericarditis, AMI), skeletal muscle causes (myxedema

muscular dystrophy seizures trauma vigorous exercise malignant hyperpyrexia), medications

(amphotericin b, clofibrate, ethanol, lithium halothane, barbiturate poisoning intramuscular

injection), other causes (renal failure, hypothyroidism, cerebrovascular accident, severehypokalemia).

3. CREATIN KINASE ISOENZYME

Normal range: CK-MB


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b. MyoglobinIt is a low molecular weight heme protein found in cardiac and skeletal muscle. Serum

levels rise in 1-4hrs and peak 6-7hrs after onset of symptoms. It will return to normal in 24

hrs.

It is most effective in ruling out AMI. Other causes that increase myoglobin serum level are

skeletal muscle injury, trauma, and renal failure.

c. Lactate dehydrogenase Normal range:-100-210 iu/l

It is a low molecular weight heme protein found in cardiac and skeletal muscle. Serum

levels rise in 1-4hrs and peak 6-7hrs after onset of symptoms. It will return to normal in 24

hrs. It is most effective in ruling out AMI.Other causes that increase myoglobin serum levelare skeletal muscle injury, trauma, renal failure.It is found in various organs and tissues like

heart, liver, lungs, kidneys, RBC. Due to lack of specificity it is not used widely. Elevation of

LDH1or ratio LDH1/LDH2 greater than 1 was used in the diagnosis of AMI.

d. Aspartate amino transferase Normal: Males-0-37iu/l

Normal: Females-0-31iu/l

It is an enzyme involved in amino acid synthesis. It is distributed in liver, heart,

skeletal muscle, red blood cells, kidneys, and pancreas. Serum level of AST rises within 12hrs. of AMI, peak in 24-48hrs, and return to normal in 3-4 days.

MISCELLANEOUS LABORATORY TESTS

1. SERUM GLUCOSE Normal- 70-110mg/dl

After AMI due to stress serum glucose will be elevated and persists for several week.

2. WHITE BLOOD CELLS

Normal-4.8-10.8*103cells/mm3

WBC may be increased in patients with AMI.


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3. ESR Normal: Males-1-15 mm/hr

Normal: Females-1-20mm/hr

It is related to acute phase reactants that increase in patient with AMI. Peak on day

4or5; remain elevated for 3-4wk.

4. LIPID PANEL

Total cholesterol and low-density lipo protein may be decreased in 48-72hrs post MI

and persist for 6-8wks.

LABORATORY TESTS USED IN THE EVALUATION OF HEART FAILURE

1. NATRIURETIC PEPTIDESThese are naturally secreted hormones that are released by various cells in response to

increased volume or pressure.

Various types of natriuretic peptides are: Atrial natriuretic peptide (ANP), B-type

natriuretic peptide (BNP), C-type natriuretic peptide (CNP), Dendroaspis natriuretic peptide

(DNP).BNP and ANP are the cardiac specific peptides. BNP is found in higher concentration

in cardiac ventricles. It is secreted by left ventricular myocytes in response to volume

overload and increased ventricular wall tension. Precursor of BNP is preproBNP which is

enzymatically cleaved into proBNP. This is again cleaved into biologically active C-terminal

32 aa BNP and inactive N-terminal-proBNP (NT-ProBNP).

Plasma levels of both BNP and NT-ProBNP are elevated due to increased volume and

ventricular myocyte stretch in patients with heart failure. These are the markers in patients

with heart failure, IHD. There levels may be varied according to gender, age, renal function;

obesity. Normal levels are higher in women than men.

a. BNP Diagnostic cutoff: 100PG/ML

b. NT-proBNP Diagnostic cut off: 125pg/ml for patients 75yrs


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OTHER BIOCHEMICAL MARKERS

CK AND CK-MM isoform will be useful for genetic screening in patients and family

members at increased risk of cardiomyopathy that will progress to heart failure.


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AIM

To analyze and interpret the lab data of a patient presented with unstable angina.

OBJECTIVE EVIDENCE

CKMB - 70

AST - 73

LDH - 550

ECG shows ST elevation.

SUBJECTIVE EVIDENCE

Patient was complaining of chest pain since morning and it was aggravated after few

times. Pain was sudden in onset which increases on strain and relieving till taking rest.

INTERPRETATION

Based on subjective evidence, the disease was diagnosed as unstable angina.

Objective evidence of cardiac enzymes like CKMB, AST, LDH were found to be elevated.

Elevation of CKMB is indicative of myocardial infection.

PLANNING

The cardiac function tests report pointing myocardial infarction in this patient. By using this

lab parameter treatment can be planned for this patient.

CONCLUSION

From the subjective and objective evidence from lab parameter was very much suggestive of

myocardial infarction.


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REFERENCE

1. Comprehensive Pharmacy Review by Leon Shargel, Alan H.Mutnaick, Paul

F.Souney, Larry N.Swanson:775789.


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MEDICATION HISTORY INTERVIEW

DEFINITION

It is defined as the process of interviewing the patient about their medications, current or

past, for the purpose of developing and planning ongoing pharmaceutical care.

The most fundamental responsibility of a clinical pharmacist is to ensure each patient

receives effective, safe and cost effective drug therapy. Drug therapy review refers to the

process by which a pharmacist reviews a patients medication regimen to ensure that the drug

therapy meets these objectives. This is a complex process which involves the assessment and

interpretation of clinical information from a diverse range of sources. The review process

draws upon the clinical pharmacists skill in pharmacotherapeutics, clinical

pharmacokinetics, adverse drug reactions, drug interactions, interpretation of laboratory dataand communication skills. For drug therapy review to be effective, these skills must be

combined with sound clinical reasoning and judgment.

Drug therapy review can take place in both hospital and community settings. In hospitals,

drug therapy review can be undertaken at any time during the patients admission, but is most

commonly performed when the patient is admitted to the hospital, during pre-ward round

preparation and during ward rounds. In acute care setting, daily review is desirable to keep up

with changes in the patients condition and drug therapy. Ideally the pharmacist should

follow the patients progress from the day of admission until the day of discharge.

As a first step in drug therapy review, pharmacists need to collect information which will

assist them to determine the appropriateness of drug therapy. This includes the patients age,

sex, body weight, social history, current and recent medication, allergy and sensitivity status,

presenting complaints, past medical history and results of relevant laboratory tests and other

investigations. This enables the pharmacist to understand the patients disease condition, the

reason why certain drugs are being administered and the patients daily clinical progress. This

understanding is the foundation for drug therapy review. Relevant information can be

obtained from a variety of sources including case notes, medication chart, nursing notes,

observational charts, and laboratory results and through discussions with medical and nursing

staff and patient interview.

When patients are admitted to a hospital, medical staff document relevant information

regarding the admission in the patients case notes. This usually includes a list of medications

which the patient is currently taking. This list may be inaccurate or incomplete, particularly in

situations where medical staffs are overburdened with patients. By speaking personally to

patients about their medications, pharmacists are able to obtain further information which

may be of importance to the ongoing medical management of the patients. Interviewing a

patient about their medications also enables the pharmacist to establish a rapport with the

patient, explain their role in patients overall care and commence preliminary counseling on


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to exacerbation of underlying diseases. Hence unless contraindicated, such type of

drugs have to be discontinued irrespective of the type of present illness.

4. While taking the treatment history do not rely on the name of the drugs told by the

patient, because often they do not tell them correctly. So always analyzing the

prescription is better.5. In case of infants, it may be required to know the medications, the mother received

during pregnancy and lactation.

REFERENCE

1. The Text Book Of Clinical Pharmacy Practice by G.Parthasarathi, Karin Nyfort

Hansen,Milap C Nahata:220222.


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PATIENT MEDICATION HISTORY INTERVIEW

1. PATIENT DETAILS

Name: Mrs. X Age: 5Month Sex: M

Date Of Birth: 12.10.2012 Date Of Admission:

02.02.13

Ip No:

79267

Height: 37 cm Weight: 5.6 Kg Social Status:

Vegetarian

Pregnancy: NA Allergies: None Address & Contact No:

2. PATIENT MEDICATION HISTORY

Sl no Name of drug Strength Direction

for use

Start date Stop date Remarks

1. Inj.Isyf-P

(Electrolyte

dextrose)

1pin STAT February

2013

February

2013

2. Inj.Amikacin

(Amikacin

sulphate)

50mg BD February

2013

NIL

3. Syp.Mintonia

(Zinc acetate),

2.5mg BD February

2013

NIL

4. FloraBC

(Lactic acid

bacillus,Niacina

mide, Vit B6)

2.5ml, TID February

2013


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3. USE OF OTC DRUGSCheck the conditions for which you have used a non-prescription medicine :( put a +

symbol where appropriate.)

Disease condition Yes No

Headache

Ear problems

Cold flue

Allergies

Sinus

Cough

Sleeplessness

Drowsiness

Weight loss

Diarrhea

Hemorrhoids

Joint pain

Rashes

Heart burn

Vitamins

Herbal products

Organic products

Others (specify)


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4. HISTORY OF MEDICAL PROBLEMSHave you noticed or do you have any of these following :( put a + symbol in the

appropriate box)


Known kidney problems

Frequent urinary infections

Difficulty in urination

Frequent urination at night

Known liver problems or

hepatitis

Trouble in eating certain

foods

Nausea or vomiting

Constipation or diarrhea+

Bloody or black bowel

movements

Abdominal pain or cramps

Frequent heart burn or

indigestion

Stomach ulcers on the past

Shortness of breath

Coughing up or tightness

Chest pain or tightness


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Fainting spells or passing

out

Sores on legs or feet

Known blood clot problems +

Leg pain or swelling

Unusual bleeding or

bruising

+

Anemia

Known hormone problems

Arthritis or joint pain

Muscle cramps or weakness +

Memory problems


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5. PATIENT MEDICAL HISTORYHave you or any of your blood relative had any of these following diseases:

Disease Self Relative

High blood pressure

Asthma

Cancer

Depression

Lung diseases

Diabetic

Heart disease

Stroke

Kidney disease

Mental illness

Drug abuse


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6. SOCIAL HISTORYPlease indicate your tobacco, alcohol, caffeine and dietary habits.

a. Nicotine

Never smoked Y

Packs per day(if smoked)

Years of use

b. Alcohol consumption

Never consumed Y

Occasionally N

Drinks/ day or week Never consumed

c. Dietary restrictions if any:

Number of meals/day - 3

Food restrictions if any (salt, sugar, fluid etc.) - Normal diet

d. Other information/comments:

Doctor advised to breast feeding in a hygienic place

Avoid contamination of food.

Clean every area of baby playing.


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1. PATIENT DETAILS

Name: Mr. X Age: 5Month Sex: M


26.02.13

Ip No:

31070

Height: 33 cm Weight:5 Kg Social Status:

Non-Smoker And Non-

Alcoholic

Pregnancy: NA Allergies: None Address & Contact No :



for use

Start

date

Stop

date

Remarks

1. Inj. Isyf-P

(Electrolyte

dextrose)

1 pint STAT February

2013

February

2013

2. Inj. Amikacin

(Amikacin

37.5mg BD February

2013

February

2013

3. sulphate) Inj.

Taxim

250mg BD February

2013

February

2013

4. (Cefotaxim)

Otrivin Mini

(Xylometazoline

Hydrochloride

2 Drops

TID February

2013


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symbol where appropriate)

5. 0.05%w/v) Syp.

AmbrodilS

(Ambroxol HCl

15mg+Salbutamol)

1mg / 5ml).

1.2ml TDS February

2013

6. Nebulization

Asthalin in NS

(Salbutamol).

0.3ml Q8H February

2013

February

2013

7. Syp. Calpol

(Paracetamol)

120mg5ml STAT February

2013


Headache

Ear problems

Cold flue

Allergies

Sinus

Cough

Sleeplessness

Drowsiness

Weight loss

Diarrhea


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appropriate box

Hemorrhoids

Joint pain

Rashes

Heart burn

Vitamins

Herbal products

Organic products

Others (specify)







hepatitis

Trouble in eating certain foods

Nausea or vomiting

Constipation or diarrhea


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movements


Frequent heart burn orindigestion


Shortness of breath

+

Coughing up or tightness +


Fainting spells or passing out


Known blood clot problems


Unusual bleeding or bruising

Anemia



Muscle cramps or weakness

Memory problems


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5. PATIENT MEDICAL HISTORYHave you or any of your blood relative had any of these following diseases:

Disease Self Relative

High blood pressure

Asthma

Cancer

Depression

Lung diseases

Diabetic

Heart disease

Stroke

Kidney disease

Neurodegenerative illness

Drug abuse

Others : Seizure birth +


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6. SOCIAL HISTORYPlease indicate your tobacco, alcohol, caffeine and dietary habits.

a. Nicotine:

Never smoked Y

Packs per day(if smoked)

Years of use

b. Alcohol consumption:

Never consumed Y

Occasionally N


c. Dietary restrictions if any:


Food restrictions if any(salt, sugar, fluid etc) - Normal Diet

d.

Other information/comments:

Doctor advised to avoid walk out side

Clean the area were baby playing

Only give soft foods


65/83





1. PATIENT DETAILS

Name: Mr. X Age: 71yrs Sex: F


26.02.13

Ip No:

2011/ 042296

Height: 172 Weight: 52 Kg Social Status:

Non-Smoker And Non-

Alcoholic




for use

Start

date

Stop

date

Remarks

1 Inj. Human

Actrapid as per

GRBS (Insulin),

As per

GRBS

TID June

2013

2. Inj.Graniset

(Granisetron)

25 mg TID June

2013

3. Inj.

Razo(Rabeprazole)

20mg BD June

2013

4. Inj. Cebanex

(Cefoperozone

500mg+sulbactum

500mg),

2g IV BD

June

2013


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3 USE OF OTC DRUGS

Check the conditions for which you have used a non-prescription medicine :( put a +


5. T. Amcard AT

(Amlodipine

5mg+atenolol 50

mg)

- OD June

2013

6.

Cap. Tamflo

(Tamsulosin),

0.4mg, 1-0-0

0.4mg 1-0-0 June

2013

7. T. Qure

(Levofloxacin)

500mg BD June

2013

8. Syp. Potklor

(Potassium

chloride)

- QID June

2013

9.

Inj. Razo

(Rabiprazole),

20mg, STAT

20mg BD June

2013

10 Inj. Graniset

(Granisetron),

25mg 1 amp,

STAT

June

2013


Headache

Ear problems

Cold flue

Allergies

Sinus


67/83


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4 HISTORY OF MEDICAL PROBLEMS

Have you noticed or do you have any of these following :( put a + symbol in the

appropriate box







hepatitis


Nausea or vomiting



movements



indigestion


Shortness of breath




69/83








Anemia




Memory problems


70/83


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6. SOCIAL HISTORY

Please indicate your tobacco, alcohol, caffeine and dietary habits.

1. Nicotine:

Never smoked Y Packs per day(if smoked)

Years of use

2. Alcohol consumption:

Never consumed Y

Occasionally N


3. Dietary restrictions if any:


Food restrictions if any(salt, sugar, fluid etc) - Normal Diet

4. Other information/comments:

Doctor advised to take plenty of water

Avoid caffeine, citrus fruit juices

Warm pad apply to abdomen to reduce bladder pressure

Wipe front to back after urination.


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1 PATIENT DETAILS

Name: Mr. X Age: 28yrs Sex: M


16.07.13

Ip No:

112572

Height: 159 Weight: 67 Kg Social Status:Smoker And Non-

Alcoholic




for use

Start

date

Stop

date

Remarks

1 Inj. H.Actrapid

(Insulin)

As per

GRBS

SC July

2013

2. IVF NS 1 pint IV July

2013

3. T.Complete TD

(Multi vitamin

tablet)

-

BD July

2013


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Headache

Ear problems

Cold flue

Allergies

Sinus

Cough

Sleeplessness

Drowsiness

Weight loss

Diarrhea

Hemorrhoids

Joint pain

Rashes

Heart burn

Vitamins

Herbal products

Organic products

Others (specify)


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appropriate box







hepatitis


Nausea or vomiting



movements



indigestion


Shortness of breath




75/83








Anemia




Memory problems

8/12/2019 C

clinical pharmacy final

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